393622599-8-3-2021-53-CC-BENN-C5LSXT-20210805141626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 393622599
Report Date: 08/03/2021
Date Signed: 08/03/2021 11:57:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2021 and conducted by Evaluator Elvira Sierra

COMPLAINT CONTROL NUMBER: 53-CC-20210609110711

FACILITY NAME:	ASFOUR, SEHAM		FACILITY NUMBER:	393622599
ADMINISTRATOR:	ASFOUR, SEHAM		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 513-4631
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	14	CENSUS: 4	DATE:	08/03/2021
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Seham Asfour		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Other-Uncleared adult in home.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On Tuesday August 03, 2021 at 10:50 a.m. Licensing Program Analyst (LPA) Elvira Sierra and Licensing Program Manager (LPM) Bettina Engelman met with Licensee, Seham Asfour to conduct an unannounced complaint inspection to deliver finding for the above complaint allegation. During today’s inspection there were four children present being supervised by 2 staff members who have all been fingerprint cleared through Community Care Licensing.
During the visit LPA and LPM inspected the home for health and safety including the off limit areas. It was alleged that the Licensee has an uncleared adult present in the daycare home. Throughout the investigation, LPA interviewed current and previous parents, licensee’s assistants, and licensee. Interviews conducted on 06/11/21 revealed that an adult has been residing in the home and the Department did not have any fingerprint clearance on record. It was unclear when the adult moved in the home. Licensee stated that the uncleared adult doesn’t have any contact with daycare children, and he/she remains in the off limits areas during daycare hours. The Department received fingerprint clearance for the individual on 06/24/21.
Report continues on subsequent page 809c---

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 53-CC-20210609110711

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: ASFOUR, SEHAM	FACILITY NUMBER: 393622599
	VISIT DATE: 08/03/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on LPA interviews conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See attached LIC 9099D page for deficiencies cited today under Title 22 Division 12 of the CA Code of Regulations. Civil penalties are being accessed. Licensee received and understood appeal rights.

An exit interview was conducted in which the report was reviewed and discussed with licensee. Notice of Site Visit was provided. Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. A copy of the LIC 9224 was provided to the Licensee.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 53-CC-20210609110711

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: ASFOUR, SEHAM	FACILITY NUMBER: 393622599
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/04/2021 Section Cited CCR 102370(d)	1 2 3 4 5 6 7	102370 Criminal Record Clearance (d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.	1 2 3 4 5 6 7	POC The Department received fingerprint clearance for Adult #1 on 06/24/21. The Licensee understands all adults living or working in her home must have fingerprint clearances prior to residing or working in the facility. A civil penalty for $100.00 for Adult #1 was assessed today.
	8 9 10 11 12 13 14	This requirement was not met as evidence by; Licensee stated during an interview on 06/11/21 that Adult # 1 moved into her home. However Adult # 1 was not fingerprinted cleared until June 24,2021. This poses an immediate health and safety risk to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3